Surgical management of metachronous bronchial carcinoma

OBJECTIVE

To assess the results of surgery for the treatment of metachronous bronchial carcinoma.

METHODS

From 1985 to 1999, 38 patients were operated on for a metachronous lung carcinoma, accordingly to the criteria of Martini. All tumors were staged using the new International Classification System revised in 1997.

RESULTS

Diagnosis of the second cancer was done at radiological follow-up in 30 asymptomatic patients. Seventeen metachronous locations were ipsilateral. Histology of the metachronous lesion was the same as that of the first tumour in 23 patients (60%). The first resection was a lobectomy (n=35), a pneumonectomy (n=2) and a carinal resection (n=1). The second one was a wedge resection (n=7), a segmentectomy (n=3), a lingulectomy (n=2), a lobectomy (n=9), a bilobectomy (n=1), and a pneumonectomy (n=16). There were five in-hospital deaths (13%). Completion pneumonectomy was performed in 15 patients, with one postoperative death (7%). The overall estimated 5 and 10-years actuarial survival rates from the treatment of the first cancer were 70 and 47% respectively. The 5-year survival rate after the treatment of the second cancer was 32% (median survival: 31 months), including the operative mortality. Survival was negatively affected by a resection interval of less than 2 years and the performance of atypical lung sparing pulmonary resection for the treatment of the second cancer.

CONCLUSIONS

Good long-term results are achievable by the means of a second pulmonary resection in selected patients with metachronous lung cancer. Optimal cancer operations should be applied whenever functionally possible.

[Postoperative complications after radiochemotherapy or chemotherapy for bronchial cancers]

OBJECTIVE

The purpose of this study was to evaluate the risk of lung cancer surgery, following induction chemo and/or radiotherapy.

METHODS

This retrospective study included 69 patients treated from January 1990 to January 1998 for a primary lung cancer in whom surgery had been performed after induction treatment. Surgery had not been considered initially for the following reasons: N2 disease (IIIA; n = 25), temporary functional impairment (2 stages IB and 2 stages IIIA [N2]; n = 4); doubtful resectability (stage IIIB [T4]; n = 40). The medical regimen resulted in combined radio-chemotherapy in 43 patients who received 2 to 4 cycles of chemotherapy (average = 2.9 +/- 0.8 cycles) and 43 +/- 8 Gy (20 to 60 Gy), or chemotherapy alone in 26 patients (3 +/- 0.7 cycles).

RESULTS

Exploratory thoracotomy was performed in 4 patients (6%). The in-hospital mortality was 9% (n = 6) from respiratory origin in all cases. There were 4 reoperations (6%): 3 for bronchial fistula and 1 for bleeding. Thirty five patients (51%) required blood transfusion (4.5 +/- 3.8 cell packs). The incidence of early and delayed bronchial fistula after pneumonectomy was 15%. Thirteen patients had a postoperative pneumonia (19%).

CONCLUSION

Surgery for lung cancer after induction chemo and/or radiotherapy is associated with an increased risk. While the mortality seems "acceptable", the morbidity rate however is high.

Early detection of airway involvement in obliterative bronchiolitis after lung transplantation. Functional and bronchoalveolar lavage cell findings

As defined by the International Society for Heart and Lung Transplantation, the diagnosis of posttransplant obliterative bronchiolitis (OB) is based on histopathologic features and/or spirometric staging criteria, using FEV(1) to determine the extent of disease. However, this last parameter reflects an advanced bronchiolar process. The present study investigated whether physiologic parameters reflecting smaller airways dysfunction on one hand, and neutrophils in bronchoalveolar lavage fluid (BALF) on the other hand, could be useful for the earlier detection of bronchiolitis obliterans syndrome (BOS). We analyzed data obtained both from 765 pulmonary function test results and from 467 BALF specimens from 45 patients who survived at least 1 yr after surgery (n = 47, including two retransplantations). Of the transplant procedures, 22 were associated with BOS and 25 were not. The mean delay from transplantation to the diagnosis of BOS was 578 d (range: 122 to 2,619 d). The threshold values of the following parameters were studied: decline in the forced expiratory flow rate at 25% to 75% of FVC (FEF(25-75)) to </= 70% of the predicted value and of baseline values, increase in the slope of the nitrogen washout curve (DeltaN(2)) > 3%, and alveolar neutrophilia >/= 20% of the total BALF cell count. Agreement on the diagnosis of BOS (using the decline in FEV(1)) was equally good for each of the four markers (kappa coefficient > 0.65, p < 10(-)(5)). In the OB group, mean delays after the threshold was reached for each of these parameters were 110 d (p = 0.09), 173 d (p = 0.03), 150 d (p = 0.003), and 131 d (p = 0.1), respectively, before the FEV(1) criteria were fulfilled. At the chosen threshold values, the decline in FEF(25-75), increase in DeltaN(2), and development of a substantial alveolar neutrophilia all occurred significantly before a decline in FEV(1) in posttransplant OB.

Pulmonary arteriovenous malformations: lung transplantation as a therapeutic option

Multiple pulmonary arteriovenous malformations (PAVM) constitute an uncommon cause of respiratory disability. They may lead to severe hypoxaemia via right-to-left shunts and are sources of substantial mortality and morbidity. Conservative surgical resection has been proposed as the treatment of choice. More recently, percutaneous balloon or coil embolization of the feeding vessels offered an efficacious and safe alternative therapy for patients whose fistulas are too numerous to excise. This study reports an unusual case of respiratory disability in a patient with multiple and microscopic pulmonary arteriovenous malformations who failed to respond to embolotherapy and who received a double lung transplantation with good initial outcome.

[Role of video-thoracoscopy in the pretreatment evaluation of lung carcinoma]

INTRODUCTION

Lung cancer is the first cause of cancer mortality in male patients in France. Treatment varies depending on the histological type and the disease extent at diagnosis.

CURRENT KNOWLEDGE AND KEY POINTS

Videothoracoscopic staging appears to be an accurate method to assess the stage of lung cancer to guide rational management as it allows for 1) an accurate tissue diagnosis when standard methods failed, 2) the identification of a parietal or mediastinal invasion when suspected by CT-scan findings, 3) lymph node sampling of sites that are poorly or not reachable with mediastinoscopy, 4) the diagnosis of pleural or pericardial metastases in patients with effusion or indeterminate nodules, and finally 5) the conclusive answer to the diagnostic dilemma caused by the presence of a contralateral pulmonary nodule in patients with a potentially curable tumor.

FUTURE PROSPECTS AND PROJECTS

Video-assisted thoracoscopy thus appears to have a complementary role in intrathoracic lung cancer staging when conventional methods are equivocal. Its main side-advantage is the opportunity to proceed without delay to the surgical treatment, when appropriate, in the same operative settings, or to perform in the same session various procedures, i.e., talc poudrage and pericardial window, to palliate adverse symptoms occurring in some of those patients. Obviously, equally efficient and less invasive approaches should have been considered previously. To date, however, videothoracoscopic evaluation of tumor resectability is not achievable. Finally, one may suppose that positron emission tomography will probably reduce the role of those invasive surgical procedures in a near future.

Distant lymph node metastases in esophageal cancer: impact of endoscopic ultrasound-guided biopsy

BACKGROUND AND STUDY AIMS

The aim of this retrospective study was to evaluate the impact of endoscopic ultrasound (EUS)-guided biopsy in patients with esophageal carcinoma where distant lymph nodes which were possibly metastatic were visualized using EUS.

PATIENTS AND METHODS

Out of 198 patients (150 men, mean age 66 years) examined over a 4-year period by EUS for local staging of esophageal cancer (121 squamous cell carcinomas and 77 adenocarcinomas), there was EUS visualization of distant lymph nodes in 40 (20%). EUS-guided biopsy was carried out in the latter patients, of cervical nodes with mediastinal tumors (n = 19), of celiac nodes with cervical tumors (n = 2) or superior mediastinal tumors (n = 9), and upper mediastinal lymph nodes in the case of distal adenocarcinomas (n = 10).

RESULTS

On EUS-guided biopsy, results were positive in 31 patients, eight were correctly negative (as confirmed by surgery), and in one patient there was a technical failure, with positive findings on subsequent surgery. The sensitivity and specificity of the diagnosis of malignant lymph nodes were therefore 97% and 100% respectively. The positive results of EUS-guided biopsy modified the tumor staging in 31 of these cases (77.5%), proving distant lymph node metastasis which is classified as stage M1. With regard to actual clinical management, surgery was withheld from 24 patients (60% of 40 cases) who were then treated with concomitant radiotherapy and chemotherapy.

CONCLUSION

EUS-guided biopsy of distant lymph nodes was indicated in 20% of patients with esophageal cancers, and the biopsy results led to upgrading of the tumor stage in about 80% of cases and influenced the treatment decision in about 60%.

[Ecoendoscopy in the assessment of esophageal neoplasms]

OBJECTIVE

To asses the diagnostic accuracy of endoscopic ultrasonography (EUS) for the local and regional staging of esophageal cancer, and its possible alteration resulting from the performance of preoperative chemoradiation.

METHODS

Prospective study of 85 consecutive patients with esophageal cancer evaluated by EUS and operated between January 1992 and December 1995. 28 of these patients had received previous induction therapy. In all cases, EUS examination was performed by the same physician not informed about the results of previous morphological explorations. Histopathological analysis of all specimens was performed by the same pathologist, not informed about the results of the EUS. Data were collected by another independent observer.

RESULTS

EUS examination resulted in incomplete staging in 8 patients (9.5%) with severe stenosis precluding endoscope passage. The accuracy, specificity and sensibility of EUS in detecting the depth of esophageal involvement (T0-2 vs T3-4) were 82.3%, 78% and 86% respectively, and 72%, 70% and 73% respectively for the lymph node metastasis. The overall accuracy of EUS in identifying the preoperative stage was 67% with a clear-cut alteration when patients had received induction therapy (61% vs 72%). On the other hand, 7(64%) of the 11 patients thought to have a complete response at endosonography had no residual tumor.

CONCLUSION

EUS provides precise information for the preoperative identification of locally advanced esophageal tumor, even after induction therapy. The latter alters the diagnostic accuracy of EUS, although complete responders could be identified in two-thirds os cases.

[Neoadjuvant therapy in advanced carcinoma of the esophagus: prognostic value of the histopathological response]

The purpose of this study was to determine the prognostic value of the histopathological response to preoperative radio-chemotherapy in patients with locally advanced oesophageal cancer. Among the 57 patients included in this open prospective study, the disease-free cervical of 48 patients who underwent an oesophagectomy was correlated with the histopathological finding. The 5-years probability of disease-free cervical was 22.1%. Cervical of the patients whose tumor had been downstaged to no residual carcinoma or superficial oesophageal carcinoma was significantly shorter than that of patients with superficial oesophageal carcinoma at presentation treated during the same period (35% vs 57%). Univariate analysis could identify 4 prognostic variables after induction therapy: adenocarcinoma, macroscopic, residual tumor, invaded oesophageal stump, and lymph node involvement. After multivariate analysis according to the Cox model, the remaining independent predictors of recurrence were: adenocarcinoma, invaded oesophageal stump, and lymph node involvement.

Operative risk and prognostic factors of typical bronchial carcinoid tumors

BACKGROUND

This study estimated operative risk and examined factors determining long-term survival after resection of typical carcinoid tumors.

METHODS

From 1976 to 1996, 139 consecutive patients (66 male and 73 female patients with a mean age of 47 +/- 15 years) underwent thoracotomy for typical carcinoid tumor. The tumors were centrally located in 102 patients (73.4%).

RESULTS

Radical resection was performed in 106 patients (7 pneumonectomies, 13 bilobectomies, and 86 lobectomies) and conservative resection in 33 (3 segmentectomies, 3 wedge resections, 20 sleeve lobectomies, and 7 sleeve bronchectomies). There were no postoperative deaths. Complications occurred in 19 patients (13.7%). The morbidity rate was not increased after bronchoplastic procedures (chi 2 = 0.033, not significant). Staging was pT1 in 107 patients (77.0%) and pT2 in 32 (23.0%); 13 patients (9.4%) had nodal metastases. Seventeen patients have died (12.2%), during follow-up, but only three deaths were related to the disease. The overall survival rate at 5, 10, and 15 years was estimated to be 92.4%, 88.3%, and 76.4%, respectively; estimated disease-free survival was 100% at 5 years and 91.4% at 10 and 15 years. Estimated survival of patients with lymph node metastasis was 100% at 5, 10, and 15 years. Univariate analysis failed to demonstrate any prognostic significance for sex, tumor size (T1 versus T2), tumor location (central versus peripheral), and type of resection.

CONCLUSIONS

These data confirm an excellent prognosis after complete resection of typical carcinoid tumors, including those with lymph node metastases. Parenchyma-saving resections should be preferred.

[Esophageal perforations and ruptures: a plea for conservative treatment]

OBJECTIVES

To identify the determinants and results on conservative management of oesophageal perforations and ruptures.

METHODS

Retrospective clinical review of 34 consecutive patients (mean age: 62 years) treated for cervical (n = 10) or thoracic (n = 24) oesophageal disruption between 1985 and 1996. Causes were: spontaneous rupture (n = 10), instrumental perforation (n = 16), alimentary foreign body (n = 6), and blunt (n = 1) or penetrating trauma (n = 1). The diagnostic delay exceeded 24 hours in 15 cases.

RESULTS

A nonoperative management was achieved in 8 patients with no mortality. A conservative surgical treatment was attempted in 23 patients, primary repair in 21 and open drainage in 2, with a 17.4% mortality. Resection (n = 2) or exclusion (n = 1) was performed in 3 patients with no early mortality, but one of them died as result of the subsequent reconstructive operation to restore oesophageal continuity. Overall morbidity was linked to the spontaneous cause of the perforation. Outcome of patients undergoing primary repair was not influenced by the diagnostic delay nor the surrounding sepsis.

CONCLUSION

Conservative management should be advocated for the treatment of oesophageal perforations and ruptures, even in case of delayed diagnostiqiagnosis, regardless of the surrounding sepsis and cause of disruption.

[Induction treatment of locally advanced operable cancers of the esophagus. Prognostic significance of the histologic response]

OBJECTIVE

The purpose of this study was to determine the prognostic significance of the histopathological response to preoperative radio-chemotherapy in patients with locally advanced oesophageal cancer.

METHODS

Among the 57 patients included in this open prospective study, the disease-free survival of 48 patients (8 females 40 males; mean age: 56.6 years +/- 8.4) who underwent an oesophagectomy after induction therapy for oesophageal squamous cell (n = 38) or adenocarcinoma (n = 10) was correlated with the histopathological findings. Chemoradiation included 2 cycles associating continuous 5 FU from D1 to 5 and from D22 to 26, cisplatyl on D1 and D22, 15 Gy/5d from D1 to 5 and from D22 to 26. Histopathological response was assessed on the operative specimens by routine examination of serial thin sections each 5 mm along the full oesophageal length, the resection margins and the lymph node dissection.

RESULTS

A wide interindividual variability was seen regarding tissue changes related to induction therapy, with a grading in tumor regression and the possibility of dissociated effects on the various treatment targets: tumor, adenopathy and vessel invasion. The 5-year probability of disease-free survival was 22% for the 48 resected patients. The presence of a complete histopathological response (n = 12) did not preclude metastatic spread in half the cases. Furthermore, it did not result in improved survival when compared to that of non-responder patients. Survival of patients who had a complete or major oesophageal response (n = 29, 35% at 5 years) was significantly lower than that of patients who were operated on during the same period for a superficial oesophageal cancer at presentation (n = 29, 57% at 5 years; P = 0.03). After multivariate analysis according to the Cox model, downstaging of the primary tumor was not identified as an independent predictor of disease-free survival.

CONCLUSIONS

Pathologic assessment of tumor regression on the operative specimen provides little prognostic information.

Colon interposition for esophageal replacement: current indications and long-term function

BACKGROUND

In contrast to the use of the stomach as an esophageal substitute, the use of the colon is becoming uncommon.

METHODS

From 1985 to 1995, 60 patients underwent colon interposition for esophageal cancer (n = 37), benign stricture (n = 13), iatrogenic fistula (n = 5), achalasia (n = 3), or necrosis of a previous substitute (n = 2). A long isoperistaltic conduit based on the left colonic artery could be used in 52 patients (86.7%). The surgical route used was through the esophageal bed in 38 patients (63.3%), under the sternum in 21 patients, and under the skin in 1 patient.

RESULTS

Colon interposition represented 18.5% of all operations performed for esophageal substitution during the study period. The choice of the colon resulted from an inadequate stomach in 33 cases (55%). The operative mortality rate was 8.3%. Seven patients (13.5%) required dilation of the esophagocolonic anastomosis. At last follow-up, 34 patients (65.4%) had no difficulty eating. Multivariate analysis identified the conduit position in the posterior mediastinum as the sole independent predictor of a good functional result (p = 0.002).

CONCLUSIONS

Colon interposition for esophageal substitution, usually performed when the stomach is not available, provides satisfactory function when placed in the esophageal bed.

Long-term complications of extraperiosteal plombage

BACKGROUND

As soon as complications due to migration of extraperiosteal plombage material had been documented, early removal became the rule. Some patients who have escaped this rule may still present with long-term complications.

METHODS

Since 1980, 14 patients aged 54 +/- 10 years were admitted 28 +/- 11 years after collapse therapy. Eight presented with signs of infection, 4 with hemoptysis, and 2 with periscapular pain. Vascular erosion, suspected in 3 patients, was demonstrated with angiograms in 1.

RESULTS

Ablation of the material was combined with excision of the devitalized ribs in 13 patients. Femorofemoral bypass was used in 2 patients for repair of an aortic erosion. Single ablation of subcutaneously migrated material was performed in a poor-risk patient. Operative bleeding was moderate except in 2 patients; 1 of them died intraoperatively during repair of an aortic erosion. A second patient died postoperatively with a massive pulmonary embolus on day 11. Infection was diagnosed in 8 patients (Mycobacterium tuberculosis, 4; and pyogens, 4). Operative outcome was satisfactory in all 12 operative survivors. A single patient presented with an infected apical space at 1 year and underwent complementary resection of the first rib.

CONCLUSIONS

We recommend routine ablation of any residual plombage material whenever operative risk is acceptable because of the high incidence of spontaneous complications.

[Endosonography in the preoperative evaluation of cancers of the esophagus]

OBJECTIVE

To assess the diagnostic accuracy of endoscopic ultrasonography (EUS) for the local and regional staging of esophageal cancer, and its possible alteration resulting from the performance of preoperative chemoradiation.

METHODS

Prospective study of 85 consecutive patients with esophageal cancer evaluated by EUS and operated on between January 1992 and December 1995. 28 of these patients had received previous induction therapy. In all cases, EUS examination was performed by the same physician not informed about the results of previous morphological explorations. Histopathological analysis of all operative specimens was performed by the same pathologist, not informed about the results of EUS. Data were collected by another independent observer.

RESULTS

EUS examination resulted in incomplete staging in 8 patients (9.5%) with severe stenosis precluding endoscope passage. The accuracy, specificity and sensitivity of EUS in detecting the depth of esophageal involvement (T0-2 vs. T3-4) were 82.3%, 78%, and 86% respectively, and 72%, 70%, and 73% respectively for lymph node metastasis. The overall accuracy of EUS in identifying the preoperative stage was 67%, with a clear-cut alteration when patients had received induction therapy (61% vs 72%). On the other hand, 7 (64%) of the 11 patients thought to have a complete response at endosonography had no residual tumor.

CONCLUSION

EUS provides precise information for the preoperative identification of locally advanced esophageal tumor, even after induction therapy. The latter alters the diagnostic accuracy of EUS, although complete responders could be identified in two-thirds of cases.

Changing patterns and surgical results in adenocarcinoma of the oesophagus

BACKGROUND

Prognosis of oesophageal adenocarcinoma is notoriously dismal. To examine the changing patterns of and treatment strategies for this disease, the longitudinal experience of a single institution over 16 years is reported.

METHODS

The study comprised a retrospective review of 551 consecutive patients operated on for oesophageal cancer between 1979 and 1995, of whom 164 had adenocarcinoma. There were 13 women and 151 men whose mean age was 61 (range 17-82) years.

RESULTS

The prevalence of adenocarcinoma (P = 0.002), that of early tumours (P < or = 0.10), and the resectability rate (P < or = 0.05) increased throughout the period whereas operative mortality rate decreased (P < or = 0.10). Surgical approach changed without influence on long-term survival. Patients referred from endoscopic surveillance programmes for Barrett's oesophagus (n = 16) had an improved survival rate compared with that of non-surveyed patients (P < or = 0.01). Overall 5-year survival after oesophagectomy (17 per cent) improved for the period 1991-1995 when compared with 1979-1982 (P < or = 0.02). Univariate analysis identified tumour node metastasis (TNM) stage, number of diseased lymph nodes, invasion of the oesophageal stump and occurrence of a postoperative complication as significant prognostic variables (P < or = 0.05). Multivariate analysis demonstrated that T stage (P = 0.0002) was the main independent predictor.

CONCLUSIONS

Recent improvement of results reflects patient selection, increased prevalence of early tumours, and dramatic reduction of the risks from oesophagectomy. New therapeutic directions should be investigated for locally advanced tumours.

Balance between alveolar macrophage IL-6 and TGF-beta in lung-transplant recipients. Marseille and Montréal Lung Transplantation Group

Acute inflammation in the lung is characterized by a phase of tissue injury followed by a phase of tissue repair. When the latter is excessive, fibrosis occurs. Alveolar macrophages (AM) can produce cytokines involved in both phases of acute lung inflammation, notably interleukin-6 (IL-6), involved in injury and transforming growth factor-beta (TGF-beta), mediating repair. We hypothesized that AM were activated in both phases, and studied IL-6 and TGF-beta production by AM during complications of lung transplantation, acute rejection (AR), and cytomegalovirus pneumonitis (CMVP). In addition, we analyzed these cytokines in bronchiolitis obliterans (BO), a fibrotic complication of lung transplantation linked to previous AR and CMVP. At the onset of AR and CMVP, IL-6 secretion increased, whereas AM TGF-beta content was increased, but not its secretion. In contrast, with time, IL-6 reached control value whereas TGF-beta secretion rose significantly. In BO, IL-6 was not oversecreted, but TGF-beta increased, notably before functional abnormalities occurred. These results show that during acute complications of lung transplantation, AM display an early activation with oversecretion of IL-6, which is involved in tissue injury, counterbalanced by a late activation in which TGF-beta predominates, mediating tissue repair. The results provide new insights into the pathogenesis of BO, which is linked to acute complications of lung transplantation through this biphasic AM activation.

Esophageal cancer resection in the elderly

OBJECTIVE

Esophageal cancer is a disease whose prognosis is dismal and its surgery involves considerable risks, consequently the opportunity of esophageal resection in elderly patients with esophageal cancer is questionnable. The aim of this study was to analyze, with respect to their age, the outcome of 386 consecutive patients who underwent esophagectomy and simultaneous replacement for cancer.

METHODS

A chart review of all patients with esophageal carcinoma admitted to our institution was undertaken for the period January 1979-December 1994.

RESULTS

The portion of patients of 70 years of age and older (14.5%) has slightly increased during the period. Location to the lower third of the esophagus and adenocarcinoma type were prevalent in the 56 elderly patients (group I), but their postsurgical TNM staging was identical to that of the 330 younger patients (group II). Other clinical features, i.e. preoperative weight loss and the presence of co-morbid diseases, however, were comparable in the two groups. Pulmonary function, as assessed by spirometry, was significantly worse among the older patients, but blood gas determinations were not different. Operative mortality was comparable, between the two groups (10.7% vs 11.2%). Major morbidity included anastomotic leak (10.7% vs 13.6%) and pulmonary complications (17.9% vs 20.6%) in both groups. Excellent palliation of dysphagia was achieved in 92% of the 50 group I patients who survived the operation. Long-term survival was not different in elderly patients (5-year rate: 17%) when compared with that of younger patients (18.9%).

CONCLUSION

These data suggest that esophagectomy can be performed safely in selected septuagenarian patients, thus allowing a substantial survival with excellent functional status in a portion of these patients.

Diagnosis by video-assisted thoracoscopy of traumatic pericardial rupture with delayed luxation of the heart: case report

Isolated pericardial rupture is probably a frequently overlooked injury. We present a case of delayed heart herniation through a left pericardial tear resulting from blunt trauma. Diagnosis was achieved by video-assisted thoracoscopy, which was also helpful in the selection of the appropriate site and extent for the thoracotomy incision.

[Subcutaneous cervical emphysema: complication of constipation. Review of the literature]

We report the case of a sixty-eight year old woman with chronic constipation, admitted in the emergency unit for respiratory deficiency and cervical subcutaneous emphysema. Endoscopy of the supradiaphragmatic air and digestive tracts was normal. Acutization of an abdominal syndrome required a laparotomy revealing a fissuration of the subperitoneal rectum on a fecal obstruction. This revealing complication may be explained by the topography of the cervico-thoraco-abdominal diffusion spaces.

[Video-assisted pulmonary excision surgery. Technique, indications and initial results]

Video-assisted thoracic surgery (VATS) is a compromise between conventional thoracic surgery performed via a thoracotomy of variable dimensions and surgical videothoracoscopy, which, using only small operating channels, requires the use of specific instruments, gives a field of vision exclusively by video camera and raises the delicate problem of extraction of the resection specimen. VATS is performed via a minithoracotomy, 3.5 to 5 cm long, using a video camera. In this way, the operator has two forms of vision throughout the operation: direct vision through the orifice of the minithoracotomy and visualization of the video screen. This technique also allows extraction of the resection specimen at the end of the operation. Between February and May 1993, 20 patients (14 males and 6 females with a mean age of 56 years) underwent lung resection by VATS (18 lobectomies and 2 pneumonectomies). Eighty-eight patients had a malignant tumour and 2 had a benign disease. Lymph node dissection was routinely performed in patients with a malignant lesion. The mean size of the tumours was 3.2 cm. The operative mortality was nil. The mean operating time was 154 minutes. The postoperative course was uneventful in 14 patients, but two cases of atelectasis on DO, one bronchial infection and one chylothorax, treated medically, were observed. The authors report the current criteria of their indications as the feasibility and reliability of this new technique. Results on pain and patient comfort, postoperative analgesia requirements, recovery of respiratory function and possible long-term sequelae remain to be demonstrated, which is the objective of a current prospective study.

Surgical reconstruction of the superior vena cava

Ten patients (eight men, two women) who underwent surgical reconstruction of the superior vena cava using an expanded polytretrafluoroethylene (ePTFE) prosthesis between 1981 and 1991 were reviewed to assess the therapeutic value of such surgery. The mean (s.d.) age was 55(12) years. Obstruction of the superior vena cava was caused by pulmonary or mediastinal cancer in nine patients and chronic mediastinitis in one. Eight patients had superior vena cava syndrome and two had symptoms of lung disease. The diagnosis of superior vena cava obstruction was made before surgery by computed tomography or superior venacavography in eight patients and during the surgical procedure in two. Tumour resection was performed in five patients. Venous reconstruction was achieved by interposition of an ePTFE graft between the proximal and distal end of the vena cava in three patients and between one (four cases) or two (three cases) tributaries of the superior vena cava and the right atrium in seven. No patient died during the perioperative period. Symptoms of superior vena cava obstruction disappeared promptly after operation in all patients. Postoperative patency was assessed by cavography or computed tomography; all the grafts were patent. During follow-up no patients presented with recurrent superior vena cava syndrome. Eight patients died. The cumulative survival rates were 70, 25 and 12.5% at 1, 2 and 5 years, respectively. Surgical reconstruction of the superior vena cava with an ePTFE prosthesis provided immediate and long-term relief of symptoms of superior vena cava obstruction with a low surgical morbidity, even in patients with unresectable malignancy.

[Tracheobronchial healing after lung and heart-lung transplantations. Apropos of 64 anastomoses]

The authors report an analysis concerning the healing of tracheo-bronchial anastomoses after lung- and heart-lung transplantation. The present study includes 64 anastomoses selected from a total of 80 cases. Sixteen had to be excluded because of early post-operative death; none of these deaths was related to an air-way complication. Bronchial healing was assessed by bronchoscopic follow-up; the appearance of the suture-line was classified according to Couraud's grades. The initial reference was the examination at 2 weeks, which was compared to subsequent follow-up. At the initial assessment, 42 anastomoses were grade 1, 4 were grade II, and 18 were grade III. The subsequent anatomic result was satisfactory for 52 sutures (81%). The complications were malacia in 2 cases, stenoses treated with a stenting device in 4 cases, dehiscence in 6 cases. The duration of ischemia and postoperative mechanical respiratory support, as well as the proximal or distal site of the anastomosis appeared to be of significant prognostic value.

Video-assisted minithoracotomy versus muscle-sparing thoracotomy for performing lobectomy

We prospectively analyzed the outcome of lobectomy in a cohort of 67 patients. Operative time, postoperative pain, pulmonary function, and early outcome were compared between the patients undergoing video-assisted techniques (n = 44) and those undergoing standard muscle-sparing procedures (n = 23). Pain was quantified daily throughout the first week using the visual analog scale. The forced expiratory volume in 1 second and the forced vital capacity were measured at days 2, 4, and 8 postoperatively. The operative time was significantly longer (p < 0.02) and the postoperative pain was significantly less (p < 0.006) in the group undergoing video-assisted procedures. Pain-related morbidity, the mean duration of air leaks, the duration of chest tube placement, and the hospital stay were all less in the video-assisted group, but the differences did not reach statistical significance. However, the impairment in pulmonary function and the overall morbidity were identical for the two groups. Based on our findings, we conclude that video-assisted minithoracotomy is a safe and reliable approach for performing lobectomies, and that the decreased postoperative pain associated with this minimally invasive approach does not result in preserved pulmonary function and significantly reduced morbidity when compared with a muscle-sparing thoracotomy.